“I
got here
about 15 minutes ago, just as you
were coming off the field from facing Duke Hammermeister.”

“Don’t
be
ridiculous. I haven’t fought today.
And the way my head hurts, I may not.”

“OK...You
know, you’re not walking so good.”

“Yeah,
maybe I should just sit here in the shade
of this babblequirk for a while.”

“This
what?”

“You
know,
the alfhast.”

“I’m
getting a
Chirurgeon….”

As
the Chirurgeon on duty at the list, you were concerned when you saw the
Duke’s
great sword strike an unimpeded blow square on top of Sir
Helmhide’s
head where
it landed with a resounding thud.
Sir
Helmhide dropped immediately. The Marshals ran to his side, and after a
long 30
seconds he slowly got up and shook his head. They helped him remove his
helm
and he was assisted off the list to his waiting squire, Reginald. All
appeared
fine at the time and you were not summoned to the field. Then Reginald
appeared. He tells you Sir Helmhide seems a bit more befuddled than
usual. He
doesn’t remember his bout with his Grace, and he’s
unsteady on his feet
and using
stranger than usual words Reginald doesn’t feel his
Knight’s quite his
usual
self and is rightly worried.

A
concussion is the most common head injury in contact sports, including
SCA
heavy combat. It is defined as any change in mental status after a head
injury.
This can include dizziness, headache, difficulty in concentrating,
changes in
vision or balance, loss of memory after the injury, or loss of
consciousness.
Fortunately, the standards for helms and blow calibration make
concussions much
less common in SCA heavy combat than in sports like high school
football. You
are probably more likely to have a non-fighter with a concussion from
accidents
at the event site, though this article will deal primarily with
fighters as
they are unique for wanting to return to the same activity that got
them
clonked in the first place. Most concussions resolve with no residual
problems,
however it is important to know the key signs to ensure you
aren’t
missing a
more serious injury.

Unfortunately,
there have been at least 16 different sets of concussion guidelines
published. One
of the more recent set of guidelines come from the AmericanAcademy
of Neurology (AAN). I will use these guidelines in this article as they
are
current and lend themselves well to the SCA setting.

The
first consideration is, as always, to the ABCs and c-spine injury. If
the
patient is unconscious, their c-spine should be immobilized and
ambulance
called for full spinal immobilization and transport. If the victim is
wearing a
helm, it should not be removed unless necessary to control the airway.
Likewise, any complaint of neck pain should be treated as a neck
fracture until
proven otherwise.

A
grade 1 concussion is defined as symptoms of a concussion lasting less
than 15
minutes and no amnesia following the injury. The fighter should be
advised not
to return to the field until they have been without symptoms for at
least 15
minutes.

In
a grade 2 concussion, the victim has no memory of events for 30 minutes
after
the injury or symptoms that last longer than 15 minutes. They can not
have been
knocked out. These fighters should be advised not to return to fighting
for a
full week after all their concussion symptoms
disappear.

A
grade 3 concussion is one that involves any loss of consciousness. If
the time
of unconsciousness was just a few seconds, the victim should be
transported to
a hospital for evaluation and stay out of contact activities until the
symptoms
have been gone for one week. If the time of unconsciousness is more
than a few
seconds, they should also be evaluated in a hospital, but should wait
for two
weeks of no symptoms before returning to fighting.

Telling
a fighter not to fight is always a touchy situation. As Chirurgeons, we
can
only make suggestions, not ban them from the field. However, in the
case of a
concussion, the suggestion should be made as firmly as possible.
Further injury
should be avoided at all costs because of the second-impact syndrome.
If a
person who is still symptomatic from a concussion receives a second
blow to the
head, even a minor one, it can result in very rapid swelling of the
brain
leading to death from herniation in a matter of minutes (think of
squeezing a
toothpaste tube…that’s what happens as the brain
tries to squeeze out
the hole
at the base of the skull). While this isn’t common (17 cases
were
reported from
1992 – 1999), it is entirely preventable.

A
less serious problem that can occur if the fighter returns to fighting
too soon
is postconcussion syndrome. A person with post-concussion syndrome can
have
fatigue, headache, unstable balance, and difficulty concentrating for
months
following the injury. Gentles with postconcussion syndrome should be
evaluated
by their physician.

These
guidelines assume that this is the first concussion the person has
suffered.
There is evidence that once you’ve suffered a concussion, you
are more
likely
to have a second one. All the guidelines recommend a longer return to
play
period following a second concussion. A third concussion in one season
bears a
universal recommendation to sit out the remainder of the season.

After
an hour of rest
and rehydration, Sir Helmhide was
only suffering from a mild headache. He was walking and threatening his
squire
normally. Since he felt pretty good, he was adamant about returning to
the
list, especially since he didn’t remember his first round.
After
gathering
together Sir Helmhide, the Marshal-in-Charge, his Lady, and a couple of
his
sword brothers, you explain to him that he has suffered a Grade 2
concussion
and he shouldn’t fight until he has been symptom free for a
week. You
make sure
he knows the decision is his, and also describe postconcussion syndrome
and
second-impact syndrome.Sir
Helmhide
feels that the risk is worth taking, however his Lady and household are
impressed with your knowledge of the injury and Sir Helmhide spends the
remainder of the day cheering on his sword brothers and helping with
waterbearing. He’s quite proud at evening court when Reginald
is named
“Most
Chivalrous” and is the tourney runner-up to Duke
Hammermeister.